How the system failed a sick man
In part two of his investigation into the fatal shooting of Vaughan Te Moananui by police, Tony Wall charts his troubled history and his sister’s quest for answers.
Vaughan Te Moananui’s story will be familiar to anyone whose relative has been squeezed between the mental health and criminal justice systems.
A father at 15, he was in trouble with the law throughout his teens and started showing signs of mental illness in his early 20s, including a couple of suicide attempts.
Alcohol would make him violent but his attempts to abstain were often thwarted by friends who’d encourage him to drink.
Te Moananui’s life started unravelling in early 2015 after an injury prevented him from working. A couple of years earlier, he cut an aunt’s finger with a knife – they’d been drinking and he’d fallen asleep. She woke him, and thinking someone was coming to attack him, Te Moananui lashed out.
That incident landed him back in the secure forensic unit at the Henry Bennett Centre in Hamilton, where doctors put him on clozapine, a last-resort anti-psychotic for people who haven’t responded to other drugs.
It is considered dangerous because it can cause convulsions and falls in blood pressure, and also has intense side-effects such as drowsiness and drooling.
Te Moananui was in the unit for about two years before returning to Thames in April 2014, but his family did not believe he was ready for release.
He moved in with his mother and stepfather Chris Simpson.
‘‘We were left to our own means when Vaughan was first released,’’ Simpson told the coroner’s inquest. ‘‘We had no idea at all about the medications that he was on.
‘‘A couple of nurses came and told us about what was going to happen . . . when he was released . . . we had no more contact.
‘‘They just said that he was responsible for giving his own medication . . . and now, in hindsight . . . that was totally inappropriate.’’
Te Moananui remained under a community treatment order, which meant he could be recalled to hospital if he failed to take his medication or drank alcohol.
A discharge letter from the Henry Bennett Centre said keeping up with his clozapine was a ‘‘most important protective factor’’ in his ongoing care.
He was under the care of the Manaaki Centre, the mental health unit at Thames Hospital, and had a key support worker and a psychiatrist.
He moved out of his parents’ home and, with his church’s help, into a rented home at Kopu. He got a job tree-trimming, which he enjoyed, and bought a car, giving him cherished independence. For a while things seemed to be going well.
But because the clozapine made him so drowsy, Te Moananui gradually reduced his dose from 350mg to 50mg, so he could stay awake for work.
His doctor, whose name was suppressed by the coroner, approved this as he felt he seemed to be doing well.
His sister says it was a mistake. ‘‘It’s not safe because it’s such a dangerous medication, it really affects the mood if you’re dropping down that quickly.’’
It became clear from evidence presented to the coroner that Te Moananui’s follow-up care was seriously lacking. Weeks or even months would go by without any visits from his doctor or key worker, whose name was also suppressed.
The key worker, who was in charge of his care plan, had dyslexia and struggled with paperwork. He often would not document all of the developments in Te Moananui’s life and his notes lacked detail.
The worker, since sacked by the DHB over unrelated issues, described in a statement to the coroner how his role had changed shortly before he took on Te Moananui, his caseload rising significantly.
He was having to do more written assessments and office work rather than the community engagement work he loved. A restructuring of the service by management had resulted in a ‘‘climate of fear’’ where staff were isolated, micromanaged and intimidated, he claimed. Anyone who spoke up was performance managed.
It led to ‘‘massive’’ staff turnover, which had an impact on consistency of care, the nurse said. He noted suicides in Waikato DHB areas had risen from 33 in 2012 to 63 in 2019. Genevieve Simpson, Te Moananui’s sister, says the nurse’s claims are an attempt at shifting the blame. ‘‘That doesn’t have anything to do with the way he did his job. He was just a really lax person.’’
But other mental health workers in Thames-Coromandel spoken to back up the nurse’s claims, saying there was a high staff turnover because of the workplace culture, which affected client care.
Vicki Aitken, Waikato DHB’s executive director of mental health, was highly critical of Te Moananui’s key worker in her evidence to the coroner, saying it was ‘‘disappointing’’ he had not kept up regular face-to-face meetings with him or discussed his care with a multidisciplinary team.
She disagreed that he had a heavy caseload – he had not raised that with management, she said.
Aitken told the coroner the nurse had received a written warning for ‘‘lack of competent care’’ of another client, and was placed on a performance improvement plan around the time of the shooting.
His employment was later terminated when it was found he’d been getting another
clinician to complete clinical reports for him.
The nurse, no longer working in the field, told the coroner he liked to work with complex clients such as Te Moananui in a relatively relaxed way, building a rapport on their level.
‘‘This did not mean that I was relaxed about handling or managing the risks. I knew that they needed to be taking their medication,’’ he said.
‘‘If I was too strict with individuals like Vaughan, I lost rapport with them, and there were risks that they would disengage from the support they needed.’’
In early 2015, Te Moananui nicked his knee with a chainsaw and couldn’t work, but couldn’t get ACC cover or help to pay his rent. Financial pressure mounted.
He was drinking again, and was severely beaten by four men at a pub.
His mother learned he was drinking and told his key worker, but he didn’t pass the information to the lead psychiatrist.
Te Moananui was last seen by his mental health team on April 2, a month before his death. The psychiatrist told the coroner he seemed to be in a good space.
Had he known about the drinking, he would have acted differently, he said. Instead, he scheduled the next meeting for three months’ time.
After the April 2 meeting, the key worker went on holiday for two weeks and there is no evidence that he handed over any comprehensive plan for Te Moananui’s care.
Coroner Michael Robb asked him how he felt about having not had contact with Te Moananui in the month before his death.
‘‘If I’m honest, there’s a lot of embarrassing moments of my follow-up with all clients and I know . . . myself and the team regularly voiced that towards management,’’ he replied.
Robb said there were numerous red flags that were missed by health workers.
Aitken told the inquest that changes had been made, including involving families more in clients’ care plans.
But Robb wanted to know what concrete policies had been introduced, in writing, ‘‘to show me that this is being implemented, that this is happening’’.
He has reserved his findings.
Ngapo-Lipscombe, the family’s lawyer, says she has no confidence that the problems have been fixed. ‘‘There is a significant risk that it can happen again, all of these systemic failures.’’
Genevieve Simpson says listening to the evidence from the key worker and doctor made her angry. ‘‘There were so many red flags.’’
Giving evidence, she told the coroner her brother was ‘‘basically sent home [from Henry Bennett Centre] with no support’’.
And she had serious concerns about the lack of support for her parents. ‘‘There was no wha¯ nau meeting with clinicians involved in his care. There was no support for them. They were just told to get Vaughan out of bed and make him find work.’’
She told the coroner that if police had approached her brother calmly and tried to negotiate, there might have been a different outcome.
She wanted training for AOS members on how to approach people experiencing psychosis.
Simpson said police should have arranged for someone from the DHB who had a good relationship with her brother to talk to him that day.
‘‘I was not experienced in how to talk to someone in the state Vaughan was in,’’ she told the coroner.
Stuff asked police a series of questions about their handling of the incident, but they declined to comment while the case was before the coroner.
Natural born social worker
About eight months after her brother’s death, Genevieve Simpson took a job as a mental health support worker, describing it as part of her healing.
She trained on the job and learned more about what had been going on with Te Moananui. ‘‘I found out . . . all his medication he was on, all the side-effects that we knew nothing about.
‘‘I found out more about the compulsory treatment order, that he could have been recalled at any time if he wasn’t complying with his medication.’’
She hadn’t expected to stay in the role for long, but as time went by, she found she was enjoying the work, and was good at it.
‘‘I’ve seen lots of really, really unwell people. It does bring stuff back, but it makes me do my job a lot better, it makes me educate people about the importance of
. . . keeping your notes up to date.
‘‘I work with the family, I like to keep the family involved in the care.’’
Her boss, Pathways team leader Amanda Purdie, says Simpson has a huge future in mental health.
‘‘She’s excellent at the job. When I hired her I think she thought it would be a short-term thing . . . because she’d only stayed in jobs six to 12 months.
‘‘But she is a natural born social worker. Her brain is just fitted for the work that we do, in that she can identify very quickly what the core issues are.
‘‘She’s a fierce advocate for vulnerable people really, she doesn’t take railroading the little guy – she gets in there and if someone’s not receiving service she will advocate for them.’’
Simpson finds the level of care provided to her brother shocking. ‘‘He was 12 months out of [Henry Bennett] and under a compulsory treatment order. I would think he’d be followed extra close, at least for the first 12 months, just because he was at high risk of reoffending or having something happen.
‘‘I blame the whole system – he was let down by mental health and then ultimately the police took his life.
‘‘But it started with the mental health system. If they had been keeping an eye on him, taking family concerns properly, things may have changed, he could have been recalled back to hospital if he was drinking.’’
Her thoughts on the system now? ‘‘It’s a mess obviously, because there’s been multiple deaths after Vaughan’s – it’s continuing to happen, there’s lack of communication, mental health clinicians aren’t really keeping the family informed, the Privacy Act is preventing families from getting any information about their loved ones.’’
Simpson is to start a bachelor of social work degree through Te Wa¯ nanga o Aotearoa next year as she takes her career to the next level.
What does she love about the job? ‘‘Just working with people from all walks of life and just being able to help them see potential in their lives – that there’s more than just their diagnosis.’’